GAIT ANALYSIS. Professor Areerat Suputtitada,M.D.

Transcription

1 GAIT ANALYSIS Department of Rehabilitation Medicine,Faculty of Medicine, Chulalongkorn University,Bangkok,Thailand 1

2 Scope in 60 mins Gait cycle: Terminology Motion analysis machines Gait determinants Gait control structures Abnormal gait Cases studies 2

3 One gait cycle 3

4 Spatial-Temporal Parameters 4 Step length 78 cm. Stride length 156 cm. Cadence 120 steps per min or 60 strides per min Stride width 5-11 cm. Foot angle 6-7 degree.

5 Gait in the young The walking base is wider. The stride length and speed are lower and the cycle time is shorter (higher cadence). 5 Small children have no heel strike, initial contact being made by the flat foot. There is very little stance phase knee flexion. The whole leg is externally rotated during the swing phase. There is an absence of reciprocal arm swinging. Mature gait is at 7 yrs old.

6 Gait velocity Cadence Gait in the elderly Stride length ('marche à petit pas') Swing phase, double-support phase Posture stooped Walking base Vertical joint movement Lateral joint movement 6

7 DILEMMA 7 Gait changes product of normal aging? Gait changes product of (age-related) disorders? Consequence: what is 'normal' gait in the elderly? Practical approach: describe suspect findings identify additional findings establish specific diagnosis or contribute findings to ageing

8 Normal data of elderly 8

9 Movements in Sagittal Plane 9 Pelvis anterior and posterior tilting Knee flexion and extension Ankle dorsiflexion and plantar flexion

10 Movements in Coronal Plane 10 Pelvis obliquity up or down Hip abduction and adduction Foot varus and valgus

11 Movements in Transverse Plane 11 Pelvis protraction and retraction Hip internal and external rotation Knee internal and external rotation Foot: In Toeing and Out Toeing

12 Clinical Gait Analysis History taking/physical examination/special tests Videotape examination: slow motion and freezing - frame Measurement of general gait parameters: cadence (steps/min), stride length (m), speed (m/s) Kinematic analysis Kinetic measurement Electromyography 12

13 Video Observation 13 Low cost/easier Advantages Permanent record for subsequent analysis. Slow motion, freeze frame facilities and time coding can all enhance greatly the accuracy of observation Disadvantages Difficult to assess rotational movement No kinematic data: joint angle No information on forces/muscle firing

14 Gait and Motion Analysis Machines 1. High speed camera and computer 14 Arrange the cameras to cover the entire measurement volume Cameras must be mounted firmly on tripods or other stable structures Isolate camera from movements or vibrations of any sort. 2. Marker, 2.5mm 40mm 3. Visual 3D software Oqus ( Hz)

15 Gait and Motion Analysis Machines 2. Force plate Pressure plate

16 Visual 3D Analysis 16 Speed, stride and cycle time Step length and step time Stance phase and swing phase Center of pressure and ground force Joint angles/force/moment/ power/velocity Segment center of gravity position Segment distal/proximal joint position

17 Kinematic analysis 17

18 Wireless EMG 18 EMG allows to directly look into the muscle. It allows measurement of muscular performance. Helps in decision making both before and after treatment. Helps patients to find and train their muscles. Allows analysis to improve sports activities. Detect muscle response in ergonomic activities.

19 Electromyography 19

20 Kinetic measurement 20

21 Attributes of Normal Walking Stability in stance Foot clearance in swing Pre-positioning of foot for initial contact Adequate step length Energy conservation 21

22 Gait Determinants-Energy conservation 1. Pelvic rotation Four degree each in the horizontal plane Forward leg movement with less lower CG Maximal rotation during double supportthe lowest point of CG in gait cycle 22

23 Gait Determinants 2. Pelvic tilt Pelvis downward during swing phase. Gluteus medius of stance limb contracts to hold pelvis in swing limb not drop too much. Vertical movement 5 degree. 23

24 Gait Determinants Early knee flexion Knee flexion 15 degree during stance phase 4,5 Knee and ankle motion Weight transfer from heel to toe in sinusoidal motion 6. Motion of CG in the horizontal plane Motion of CG 2 inches from stance phase in one limb to another limb

25 Ankle and foot during push off 25 Ankle rockers

26 Gait Determinants 26 Sinusoidal movement in vertical and horizontal plane 2 inches each Highest at midstance Lowest at double support Most lateral at midstance Energy conservation

27 basal ganglia coordination of movement elements cerebellum sequencing of movement elements alpha-mn activation gamma-mn activation GAIT CONTROL STRUCTURES contraction motor cortex spine and joints frontal lobe 27 parietal lobe visuo-acousticospatial integrat. brainstem brainstem orthostatic reflexes spinal cord PNS muscles spinal reflexes spinal cord PNS muscles spine and joints muscle spindel afferences force joint position visual system vestibular system acoustic system movement

28 GAIT CONTROL STRUCTURES frontal lobe basal ganglia motor cortex parietal lobe 28 visual system cerebellum brainstem brainstem vestibular system spinal cord spinal cord acoustic system PNS PNS muscles muscles spine and joints spine and joints

29 JOINTS 29 Osteoarthrisis Spinal degeneration Spondylitis HLA B27 Stiff gait

30 GAIT CONTROL STRUCTURES frontal lobe basal ganglia motor cortex parietal lobe 30 visual system cerebellum brainstem brainstem vestibular system spinal cord spinal cord acoustic system PNS PNS muscles muscles spine and joints spine and joints

31 MUSCLE 31 Polymyositis/dermatom. Polymyalgia rheumatica Myopathy Ischemia Amyotrophic lateral sclerosis CK, skin changes, paraneoplastic pain, CK normal CK, EMG peripheral arterial occlusive disease gait disorder not usually presenting feature Paretic gait

32 GAIT CONTROL STRUCTURES frontal lobe basal ganglia motor cortex parietal lobe 32 visual system cerebellum brainstem brainstem vestibular system spinal cord spinal cord acoustic system PNS PNS muscles muscles spine and joints spine and joints

33 NERVE Polyneuropathy diabetis mellitus, alcoholism, neoplasms, dysproteinemia CIDP: conduction blocks Mononeuropathy diabetis mellitus Plexopathy neoplasms Polyradiculitis Guillain-Barré syndrome: CSF protein, GM antibodies Cauda syndrome spinal stenosis: MR imaging Post-polio syndrome history 33 Paretic gait

34 GAIT CONTROL STRUCTURES frontal lobe basal ganglia motor cortex parietal lobe 34 visual system cerebellum brainstem brainstem vestibular system spinal cord spinal cord acoustic system PNS PNS muscles muscles spine and joints spine and joints

35 Myelopathy Syrinx Tumors SPINAL CORD 35 Her. spastic paraparesis cervical myelopathy pathological fractures: osteoporosis metastasis multiple sclerosis intramedullary extramedullary meningeoma Spastic gait Ataxic gait

36 GAIT CONTROL STRUCTURES frontal lobe basal ganglia motor cortex parietal lobe 36 visual system cerebellum brainstem brainstem vestibular system spinal cord spinal cord acoustic system PNS PNS muscles muscles spine and joints spine and joints

37 BRAIN STEM 37 Progressive supranuclear palsy Infarction Vertebrobasilar insufficiency downward gaze bradykinesia dementia Toppling gait falls without prevention severe dysequilibrium

38 GAIT CONTROL STRUCTURES frontal lobe basal ganglia motor cortex parietal lobe 38 visual system cerebellum brainstem brainstem vestibular system spinal cord spinal cord acoustic system PNS PNS muscles muscles spine and joints spine and joints

39 CERBELLUM 39 Toxic cerebellopathy Drug-induced cp. Paraneoplastic cp. Radiation-induced cp. Infarction alcohol phenytoin Ataxic gait

40 basal ganglia GAIT CONTROL STRUCTURES frontal lobe 40 motor cortex parietal lobe visual system cerebellum brainstem brainstem vestibular system spinal cord spinal cord acoustic system PNS PNS muscles muscles spine and joints spine and joints

41 MOTOR CORTEX 41 Infarction/haemorrage Tumors Falx meningeoma hemiparesis hemiparesis paraparesis stiff gait

42 basal ganglia GAIT CONTROL STRUCTURES frontal lobe 42 motor cortex parietal lobe visual system cerebellum brainstem brainstem vestibular system spinal cord spinal cord acoustic system PNS PNS muscles muscles spine and joints spine and joints

43 BASAL GANGLIA 1 43 Parkinsonian syndromes idiopathic Parkinson's disease (IPD) multiple system atrophy (MSA) Freezing gait with festination

44 BASAL GANGLIA 2 44 Dystonia idiopathic d. tardive d. Stiff gait

45 BASAL GANGLIA 3 45 Chorea dementia Ataxic gait coordination, dysmetria, wide-based, irregular movements

46 basal ganglia GAIT CONTROL STRUCTURES frontal lobe 46 motor cortex parietal lobe visual system cerebellum brainstem brainstem vestibular system spinal cord spinal cord acoustic system PNS PNS muscles muscles spine and joints spine and joints

47 FRONTAL LOBE 47 Tumors Normal pressure hydrocephalus (NPH) gait initiation apathy disinhibition reasoning Hakim trias: gait disorder dementia urine incontinence Freezing gait without festination

48 GAIT CONTROL STRUCTURES frontal lobe basal ganglia motor cortex parietal lobe 48 visual system cerebellum brainstem brainstem vestibular system spinal cord spinal cord acoustic system PNS PNS muscles muscles spine and joints spine and joints

49 PARIETAL LOBE 49 Infarction/haemorrhagia Tumors Chronic subdural haematoma Veering gait gait deviation in one direction Cautious gait slow, short-stepped, shuffling normal: base, freezing, gait initiation

50 basal ganglia GAIT CONTROL STRUCTURES frontal lobe 50 motor cortex parietal lobe visual system cerebellum brainstem brainstem vestibular system spinal cord spinal cord acoustic system PNS PNS muscles muscles spine and joints spine and joints

51 VISUAL SYSTEM 51 visual acuity visual field age-related acuity accomodation contrast sensitivity glare sensitivity dark adaptation depth perception retinal degeneration cataract hemianopia Cautious gait

52 basal ganglia GAIT CONTROL STRUCTURES frontal lobe 52 motor cortex parietal lobe visual system cerebellum brainstem brainstem vestibular system spinal cord spinal cord acoustic system PNS PNS muscles muscles spine and joints spine and joints

53 VESTIBULAR SYSTEM 53 Acoustic neurinoma tinnitus deafness gait disorder Veering gait gait deviation in one direction

54 basal ganglia GAIT CONTROL STRUCTURES frontal lobe 54 motor cortex parietal lobe visual system cerebellum brainstem brainstem vestibular system spinal cord spinal cord acoustic system PNS PNS muscles muscles spine and joints spine and joints

55 ACOUSTIC SYSTEM 55 Presbyacusis Cautious gait

56 FREEZING GAIT 56 Findings Mechanism gait initiation turning blockades at narrowings normal: base access to brainstem locomotor centres FG with festination/hastening Impairment basal ganglia FG without festination/hastening Impairment frontal lobe parietal lobe vermis atrophy (gait ignition failure)

57 Parkinson 57

58 HIERARCHY OF GAIT CONTROL STRUCTURES frontal lobe gait initiation 58 parietal lobe visuo-spatialacoustic integration visual system visual gait control basal ganglia coordination of movement elements vestibular system vestibular gait control brainstem orthostatic reflexes cerebellum sequencing of movement elements spinal cord afferent conduction efferent conduction spinal reflexes PNS muscles muscle spindles afferences joint afferences motoneurons force production spine and joints mechanics

59 Simplified Gait Analysis Check Sheet 59 Moseley & Moore et al 1993

60 Case study 60

61 Case study 61

62 Case study 62

63 Case study 63

64 Case study 64

65 Case study 65

66 Case study 66

67 Case study 67

68 Case study 68

69 Quit What is the most likely diagnosis in a patient with the stance duration of 55%? A. Ataxia B. Antalgic gait C. Balance problem D. Child 69

70 Normal stance=60%. 55% is shortened stance. Answer Ataxia and balance problems trend to result in increased stance duration. Children have longer stance times compared to adults. Stance is shortened due to pain (antalgic gait). 70

71 What is the muscle? 71

72 Answers 72

73 Take Home Messages 73 Clinical gait analysis is used together with the history, physical examination and other special investigations to perform a detailed assessment of a patient with abnormal gait. It usually consists of 5 elements: videotape examination, measurement of general gait parameters, kinematic analysis, kinetic measurement, and elctromyograpky (EMG). The human eye is simply not fast enough to capture and process all of the events that occur during an average gait cycle. Video recording of walking can providing a permanent record of the walk for subsequent analysis. Slow motion, freeze frame facilities and time coding can all enhance greatly the accuracy of observation. Computerized gait analysis by combining kinematic and kinetic data, is possible to calculate the joint moments and powers in three dimensions. The joint angle, moment and power,and the EMG for specific muscles,provide a detailed description of the mechanics of gait. Such information enhances much better decisions to be reached on the best way to treat the patients.

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